| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,224 |
1,261 |
$149K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,093 |
2,087 |
$137K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
263 |
189 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
1,411 |
1,406 |
$97K |
| D0210 |
Intraoral - complete series of radiographic images |
1,659 |
1,655 |
$78K |
| D1120 |
Prophylaxis - child |
1,573 |
1,565 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,009 |
3,040 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
902 |
573 |
$49K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
500 |
370 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,343 |
2,334 |
$33K |
| D1110 |
Prophylaxis - adult |
298 |
297 |
$26K |
| D9430 |
|
816 |
790 |
$26K |
| D1351 |
Sealant - per tooth |
687 |
172 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,038 |
1,035 |
$22K |
| D2954 |
|
168 |
125 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,386 |
1,272 |
$17K |
| D0350 |
|
1,666 |
766 |
$13K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
27 |
21 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
101 |
43 |
$12K |
| D4341 |
|
130 |
37 |
$9K |
| D0272 |
Bitewings - two radiographic images |
102 |
98 |
$1K |
| D0270 |
|
234 |
230 |
$1K |
| D4910 |
|
13 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
39 |
39 |
$878.50 |